HIPAA
If your organization’s existing HIPAA authorization form does not cover this request, below is a draft HIPAA Authorization form for your consideration and/or use that you may print, have your patient complete, and then maintain for your own records.

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The Leukemia & Lymphoma Society (LLS) is the world's largest voluntary health agency dedicated to blood cancer. The LLS mission: Cure leukemia, lymphoma, Hodgkin's disease and myeloma, and improve the quality of life of patients and their families. LLS funds lifesaving blood cancer research around the world and provides free information and support services.

The Leukemia & Lymphoma Society is a 501(c)(3) organization, and all monetary donations are tax deductible to the fullest extent allowed by tax laws. Please check with your financial advisor if you have more questions.